Self-management via a mobile app is a new, cost-effective method for delivering first-line treatment for urinary incontinence (1, 2). The aim of this study was to analyse which factors were associated with completing self-management and with improvement when the app was made freely available for everyone.

A pragmatic, observational study evaluated the implementation of a mobile app focused on Pelvic Floor Muscle Training (PFMT). When downloading the mobile app Tät®, the user was informed about the study and asked to answer a questionnaire. The participant provided information on age, educational level, current residence, app language and the validated ICIQ- UI SF questionnaire (International Consultation on Incontinence Modular Questionnaire – Urinary Incontinence Short Form). If still using the app after 3 months, the user was asked to answer a follow-up questionnaire. This included the ICIQ-UI SF, the validated PGI-I questionnaire (Patient Global Impression of Improvement) and questions on frequency of PFMT and app use. Answering the questionnaires were optional and submitting the questionnaires was considered as consenting to participation. Questionnaires were submitted anonymously and could not be traced back to the participant.

The study included participants who downloaded the app between May 2015 and April 2017. The inclusion criteria were age ≥18 years and urinary incontinence, defined as reporting any frequency and any amount of leakage in the ICIQ-UI SF questionnaire. The answers from the baseline questionnaire were analysed using multivariate logistic regression for association with completed self-management (defined as submitting the follow-up questionnaire within 135 days). The answers from baseline and follow-up were analysed in a second regression model to find any association with improvement according to the PGI-I. Factors in both models were then removed stepwise until only factors with significant association (p≤0.05) to the outcome remained. Age (categorized) was controlled for throughout the analysis.

In total, 13 257 people were included in the first analysis. Their mean age was 40.2 years (range 18 -98) and 690 used the English app. They had a mean ICIQ-UI SF score of 8.6 (SD 4.0). Of the total group, 1 861 (14.0 %) completed the 3 months of self-management. Only 1 610 participants were included in the second analysis because 251 people had an older version of the app in which the PGI-I questionnaire was not included. Due to the construction of the electronic questionnaire there were no missing answers for any of the other variables. 

Four factors showed significant association with completing treatment: age, university education, episodes of stress incontinence and use of the English app (table 1). Together, these variables accounted for 2.7% (Nagelkerke R square) of the variability.

At follow-up, 1 094 participants (68%) reported improvement. Four factors were significantly associated with improvement: episodes of stress urinary incontinence, use of the English app, and higher frequency both of PFMT and of app use (table 1). These factors explained 23.2% of the variability (Nagelkerke R square).

Episodes of stress urinary incontinence and English app language were factors associated with both completion of self-management and improvement. Previous research has also shown a better effect of PFMT among women with stress urinary incontinence compared to other types of urinary incontinence. Additionally, the app was designed for women with stress urinary incontinence. The incongruent association of the app language could be due to the relatively few English users and that the app was developed to correspond to Swedish conditions.

Educational level predicted completion of self-management but not improvement. This could be a reflection of the association between educational level and the adoption of health apps (3).

Higher frequency of PFMT and use of the app were both associated with improvement, and the effect was not only associated to the amount of training. It is possible that the graphic support improved the quality of the training. The app also included information on incontinence, the pelvic floor and lifestyle advice that could explain this additive effect.

Since background factors only accounted for a small part of the variability, these results cannot support a recommendation of self-management for certain patient groups. More research is needed to evaluate whether other factors could better predict completion of self-management. 

These results suggest that the app works better for the intended group with stress urinary incontinence. The inconsistent association of app language indicates a need for more research to evaluate the app in different cultural contexts. Further, the results support the recommendation of doing regular PFMT, but also indicate that using the app has other advantages than merely increasing adherence to PFMT.

Asklund I, Nyström E, Sjöström M, Umefjord G, Stenlund H, Samuelsson E. Mobile app for treatment of stress urinary incontinence: A randomized controlled trial. Neurourol Urodyn. 2017;36(5):1369-76.
Sjöström M, Lindholm L, Samuelsson E. Mobile App for Treatment of Stress Urinary Incontinence: A Cost-Effectiveness Analysis. J Med Internet Res. 2017;19(5):e154.
Carroll JK, Moorhead A, Bond R, LeBlanc WG, Petrella RJ, Fiscella K. Who Uses Mobile Phone Health Apps and Does Use Matter? A Secondary Data Analytics Approach. J Med Internet Res. 2017;19(4):e125.